short and insightful writing about a long and complex history

Does “Public Health” Really Want To Own Addiction?

Editor’s Note: Guest blogger and medical anthropologist Kim Sue returned from a recent conference entitled “From Punishment to Wellness: A Public Health Approach to Women and the War on Drugs” with some questions about the coherence of the public health paradigm.

To celebrate the release of a joint report published by the New York Academy of Medicine (NYAM) and the Drug Policy Alliance (DPA) entitled a Blueprint for a Public Health and Safety Approach to Drug Policy, WORTH (Women on The Rise Telling Herstory) organized a conference focusing on women and the War on Drugs. The conference brought together formerly incarcerated women, direct service providers, researchers, policy analysts, and advocates and activists to discuss how to move from a criminalization model of drug use to a public health model. “The war on drugs is more than a failure,” the organizers announced. “It has swollen the prison system, left millions of people with criminal records and damaged communities.” The one-day event was aimed at exploring “practical examples of public health alternatives,” through discussions around four main themes: prevention, treatment, harm reduction, and safety.

Thinking through public health at the New York Academy of Medicine.

What was interesting to me during the panel sessions and the break-out groups was the relative absence of public health professionals and clinicians in these discussions (one notable exception was Professor Lynn Roberts of Hunter College’s Department of Community Health). While “public health” was one of the buzzwords of the day, it seemed to stand in for other things that the conference attendees were actually more interested in talking about: structural violence, poverty, racism, patriarchy—often referred to as the “structural determinants of health.” One possibility is that “public health” was being used rhetorically as a means to talk publicly and politically about race, class, gender and various axes of social inequality under “public health’s” cloak of respectability.

There was some discussion of specific legislation and public-health oriented programming by several of the speakers—for example, Good Samaritan Acts, needle exchange programs, the decriminalization of sex work, and bills against the criminalization of HIV status—but the conference neglected how the massive apparatus of the War on Drugs endeavor will be “public health-ified” on a large scale. What will be the unintended consequences of doing so?

I think it’s important to have conceptual clarity when we discuss these issues. gabriel sayegh, of the Drug Policy Alliance, alluded to the some of the imprecision in the term when he spoke about the Obama administration’s recent pronouncements on the War on Drugs with the 2013 release of its National Drug Control Strategy.

Gil Kerlikowske, drug czar.

Gil Kerlikowske, director of the Office of National Drug Control Policy, has stressed the importance of a public health approach. “Drug policy reform should be rooted in neuroscience—not political science,” Kerlikowske avers. “It should be a public health issue, not just a criminal justice issue. That’s what a 21st-century approach to drug policy looks like.”

Yet as sayegh pointed out, the plan was really that the President’s “public health approach is going to be through drug courts.” sayegh noted that this is not really a public health approach per se: rather, it represents a refusal to let go of the criminalization model “since it lets judges, prosecutors and cops continue to say what a health-based approach is.”

Yet what exactly is a health-based approach, and how does it differ from a public health approach? This distinction between public health and clinical medicine is critical. The two fields have historical and ongoing accommodations and antagonisms—to use historian of medicine Allan Brandt’s terms—as well as important philosophical, methodological and empirical differences between them. In reference to the War on Drugs, does a “health-based” approach mean that drug use is a problem primarily to be solved within the confines of a doctor-patient relationship? Does it mean that all treatment should be billable, insurable, and disease-specific? Does it include peer-recovery or finding God under its rubric? How is a “public health” approach different from a predominantly medical orientation?

Public health/medicine and criminalization have a long history of jockeying to be the dominant paradigm for addressing addiction and drug use in the United States. And I generally agree that a public health paradigm is a better, safer and more humane alternative than the current criminalization of drug use. But does the public health field even want to “own” addiction as one of its many causes, when addiction can be seen as a sociocultural phenomenon, even an epistemological stance towards the world, just as much as it can be seen as a problem for population health? How does addiction fit into the traditional public health realms of biostatistics, infectious disease, environmental exposures and epidemiology?

Eva Bertram and her colleagues make a convincing argument in their 1996 book, Drug War Politics: The Price of Denial. “First, a clinical, medical approach to many health problems is insufficient,” they contend. “Second, it is far more effective—and, in the case of health problems without a cure, absolutely imperative—to prevent rather than to treat many health problems. Third, prevention demands attention to the physical and social environment that causes or exacerbates health problems. And fourth, attention to the broader environment demands a response by the public; it is beyond the control of individuals alone and beyond the reach of physicians” (194). If the American Public Health Association’s annual conference is any reflection of the field’s willingness to embrace the War on Drugs as a public health issue, then their choosing prison abolitionist Angela Davis as the conference’s closing speaker is an indication that public health practitioners are confronting the criminalization alternative.

Drug Policy Alliance poster for a state Good Samaritan Law, an example of recent state-based public health interventions to reduce opiate overdose deaths.

As politicians and advocates move forward in advancing an agenda in which incarceration is not the main form of “treatment” for addiction, and as we undergo many of the changes laid out in the Affordable Care Act, we need to be careful how we speak about public health. Public health, at its worst, studies and measures “health behaviors” (of individuals) and demands a ceaseless supply of studies to demonstrate both effectiveness and efficacy of interventions. Some public health interventions can engage in fear-mongering and produce risk, blame and shame in their efforts, identifying “risky” lifestyles and behaviors. At its best, public health projects can address the complex etiology and interactions between individuals and their environments as well as focusing on the “upstream” societal factors—poverty and inequality, to name a couple—that are such important forces in determining one’s life chances.

5 thoughts on “Does “Public Health” Really Want To Own Addiction?”

Nice one, Kim. I think certainly, given that you are yourself a physician in training, we have to recognize the critical role of health professionals in “taking hold” of this conversation about “public health” –defining it and operationalizing it. There are many who are using its ‘cloak’ to tout a gentler drug war. The definition of health has to be broad and the WHO definition of health fits in well — which covers mental, physical, and spiritual health and well-being. With a culturally sensitive, inclusive definition of health, we’ll be able to recognize some drug use behaviors as decidedly “not dangerous and unhealthy” and thus warranting criminal sanction (eg. non-toxic psychoactivation with cannabis in the context of spiritual practice, social convivality, or other social norms). It has to be a public health framework in line with WHO’s all-inclusive health definition, the human right to health, social determinants of health, and all the rest of it. And definitely, health professionals have to take the lead.

This is really important, Sunil. I think that engaging in broader cultural orientations towards drug use is critical and historians would be some of the first to point out how and why these changes come about. I also am interested in how we speak of ‘human rights’ of drug users in overseas/global discourses (with very egregious violations on people’s bodies and spirits happening abroad) but you tend not to hear about a human rights framework for drug users here in the US.

PS: I’m an Associate Member of NYAM and work with DPA on several projects related to public scholarship. You can find my NYAM application statement here: https://www.facebook.com/notes/sunil-kumar-aggarwal/my-application-letter-to-the-new-york-academy-of-medicine-highlights-cannabis-en/10150940347429856
Here is an excerpt: “As stated in numerous Academy whitepapers and testimonies, the importance of taking a sincere public health approach grounded in human rights in which the criminal law and civil penalization play no role with regards to nonviolent behavior related to the possession and use of such substances is absolutely necessary if urban populations are to no longer be decimated by the uneven application of current laws and the violent underground markets that such policies generate. Furthermore, the importance of objectively and fairly assessing the health effects, both beneficial and deleterious, of such substances is necessary so that health leaders are able to offer sound public safety and harm reduction messages and if the therapeutic benefits of such substances are to be fully availed.”

[…] This piece at the ever interesting Alcohol and Drugs History Society’s Points blog asks whether there’s any appetite in the public health community to ‘own’ the issue alongside the many other issues that they have traditionally addressed. And it points out that public health measures can also mean: […]